REQUEST FORM- ANTIGEN TEST KITS AND MASKS

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1 BOX ANTIGEN TEST KIT HAS = 5 TESTS | 1 BOX OF MASK HAS = 20 MASKS

Email *

PLEASE FILL IN THE FOLLOWING DETAILS

Privacy Act and Personal Information Protection and Electronic Documents Act:

We are collecting information for the project in compliance with the Privacy Act, and the Personal Information Protection and Electronic Documents Act. Hence, anyone in the team is required to comply with the same.

Do You Agree With The Above Act? *

YES

Required

DATE Y/M/D *

NAME *

PHONE NUMBER *

PLEASE STATE THE NUMBER OF ANTIGEN TEST KIT YOU REQUIRE (1 BOX ANTIGEN TEST KIT HAS = 5 TESTS) *

PLEASE STATE THE NUMBER OF MASKS YOU REQUIRE ( 1 BOX OF MASK HAS = 20 MASKS)

PLEASE NAME THE COMMUNITY AND/OR ORGANIZATION YOU PROVIDE SERVICES TO *

COMMUNITY AND/OR ORGANIZATION PHONE NUMBER *

COMMUNITY AND/OR ORGANIZATION REGISTERED RESIDENTIAL/OFFICE ADDRESS *

YOUR ARE REQUESTED TO KEEP A RECORD OF DISTRIBUTION WITH THE HELP OF THE FOLLOWING FORM

https://forms.gle/xtu6SGxaBwepfEAA7

COMMENTS

THANK YOU!

Use and availability of COVID-19 Screening Tests and masks: If COVID-19 Screening Tests and masks are provided by the GAC to the Participant Organization, then the Participant Organization will only use the COVID-19 Screening Tests in Canada (and will not be exported or used elsewhere). The Participant Organization will not utilize the COVID-19 Screening Tests or masks for purposes outside of the Permitted Purposes or sell or otherwise assign or dispose of the COVID-19 Screening Tests or masks without the consent of the GAC in writing.

A copy of your responses will be emailed to the address you provided.

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